HYPOTHETICAL CASE STUDY

Renal Replacement Therapy

in a Patient with Acute Kidney

Injury following Subarachnoid

Hemorrhage

2

INITIAL PRESENTATION

• 46 y.o. female presenting to the Emergency

Department with the worst headache of her life

and increasing lethargy

• Non-contrast CT of the head demonstrates

subarachnoid hemorrhage (SAH) with extension

into the ventricles (Hunt Hess classification grade

4)

• Patient is immediately intubated stat at the

bedside and taken to the cath lab where she

underwent coiling of right ACOMM aneurysm

• Vitals: BP 125/72, HR 82, RR 14, Temp 98.2 F, O2

saturation on room air 97%

• Labs: Na 142, K 4.4, BUN 18, Cr 0.75, WBC 10.6,

Hgb 14.2, Platelets 274K

• CXR clear

• Body weight: 68 kg

• Unremarkable

• One C section delivery at the age of 35

• MVI

Patient presenting

Medical history

Medications

I

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A. Patients with aneurysmal subarachnoid hemorrhage (SAH) are at risk for

vasospasm and typically remain in the ICU for at least 14 days to undergo

close monitoring. 1

B. Hypertonic saline and norepinephrine are administered to treat cerebral

edema, prevent vasospasm and delayed cerebral ischemia, and improve

prognosis. 1,2

C. Development of acute kidney injury (AKI) following SAH can be associated with

fluid delivery, vancomycin administration and clinical vasospasm. 3

Management of Subarachnoid Hemorrhage (SAH)

AKI is a serious complication of SAH 2,4,5

INITIAL PRESENTATION DISCUSSIONI

AKI doubles in-hospital

mortality for SAH and

increases the likelihood that

patients will suffer poorer

recovery.4,5

A study of 260,885 hospital

inpatients showed a 4%

incidence of AKI following

SAH. Nearly 7% of SAH

patients who developed AKI

required RRT. 4

Despite improved management of SAH, AKI remains a serious

complication that negatively affects patient outcomes and may

require treatment with RRT.4-7

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• Patient is in stable condition

• Intubated, PRVC TV 500 RR 14 FiO2 80% peep 5 cm

H20

• 3% saline initiated @ 60 cc/hr to maintain serum

sodium 150-155

• Norepinephrine initiated to maintain SBP >140

• Net fluid balance: 12 Liters

• BP: 145/92 on norepinephrine drip

• HR: 100

• Temperature: 99.2 F

• Body weight: 78 kg

• Oxygen saturation: 100%

• SCr: 1.55 mg/dL

• BUN: 46 mg/dL

• Na: 151 mEq/L,

• Plasma potassium: 4.4 mEq/L

• Urine output: 5 cc/hour

• PAC CVP: 16 mm Hg, Wedge: 23 mm Hg, CO: 4.8 L/min

Patient status

Signs and symptoms

Test results

ICU DAY (Day 5)II

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AKI Stage SCr Urine output

11.5–1.9 times baseline

or ≥0.3 mg/dL (≥26.5 μmol/L) increase

<0.5 mL/kg/hr for

6–12 hours

2 2.0–2.9 times baseline<0.5 mL/kg/hr for

≥12 hours

3

3.0 times baseline

or increase in SCr to ≥4.0 mg/dL

(≥353.6 μmol/L)

or initiation of RRT

or in patients <18 years, decrease in

eGFR to <35 mL/min per 1.73 m2

<0.3 mL/kg/hr for

≥24 hours

or anuria for

≥12 hours

The patient meets KDIGO criteria for Stage 2 AKI 12

A. Extent of fluid overload

B. Need to maintain hemodynamic stability and control intracranial

pressure

C. Available resources in terms of dialysis machines and trained staff

D. Ability to coordinate dialysis with other therapies including

antibiotic therapy

Several factors influence choice of renal replacement therapy

ICU DAY (Day 5) DISCUSSIONIII

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RRT after SAH or other acute brain injury is challenging 6

A. CRRT

B. SLED*

C. Intermittent hemodialysis

D. Other

What modality of RRT might you use for this patient? Why?

*Includes sustained or slow low-efficiency dialysis, slow extended dialysis, sustained

low-efficiency daily dialysis, and sustained low-efficiency daily diafiltration

INITIATION OF DIALYSIS DISCUSSIONIV

Fluid overload is associated

increased mortality in critically

ill patients with AKI. 8,9

Positive fluid balance is also

linked to adverse neurologic

outcomes in SAH and other

acute brain injuries. 10

SAH patients are vulnerable to

blood pressure fluctuations

and osmotic shifts. 3,6,7,11,12

Optimizing hemodynamic

stability and avoiding rapid

shifts in osmolality are key to

good outcomes. 3,6,7,11,12

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• Body weight: 78 kg

• Dose: 35 ml/kg/hr*

• Filter:

• BFR: 180 ml/hr

• PBP: N/A

• Dialysate: CRRT Solution BGK4/2.5 (5000 ml)

• Replacement: no replacement

• Net fluid removal: 200 cc/hour

• Anticoagulation: heparin 200 units/hour*Dose selected in accordance with KDIGO guidelines

Patients with the diagnosis of aneurysmal SAH are at

increased risk of vasospasm (especially Days 3-14 post-

bleed). Hemodynamic fluctuations can provoke

vasospasm.

• Fluid removal without compromising blood

pressure and cerebral blood flow

• Need for hemodynamic stability

• Need to avoid rapid osmotic shifts

Prescription

Clinical Rationale for choice

Clinical considerations

INITIATION OF CRRTIV

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CRRT is associated with improved hemodynamic stability and more

controlled fluid balance compared with intermittent RRT 13-16

While intermittent RRT may

cause considerable

fluctuations in fluid balance,

CRRT is noted for its slow and

steady removal of fluid and

solutes 13,14

Current clinical practice guidelines recommend the use of continuous

RRT in AKI patients with acute brain injury or other causes of increased

intracranial pressure or brain edema 13,15,16

INITIATION OF CRRT DISCUSSIONIV

In patients with acute brain

injury, such as SAH,

intermittent RRT may worsen

neurologic status by impairing

cerebral perfusion and

increasing cerebral edema and

intracranial pressure 3,6,7,11,12

KDIGO 15

We suggest using CRRT, rather than intermittent RRT, for

AKI patients with acute brain injury or other causes of

increased intracranial pressure or generalized brain

edema.

ADQI 13,16CRRT is recommended over intermittent hemodialysis for

patients with ARF who have, or are at risk for, cerebral

edema.

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Day 0 Day 1 Day 5 Day 10 Day 14

Presentation ICU arrivalCRRT

started

CRRT

completedICU discharge

SCr

(mg/dL)0.75 0.90 1.55 0.80 0.75

BUN

(mg/dL)18 26 46 21 21

K+

(mEq/L)4.2 4.6 4.4 4.1 4.1

Urine output

(mL/hr)50 30 5 40 40

Body weight

(kg)68 70 78 72 70

BP

(mmHg)

Wedge

(mmHg)

125/72

N/A

135/82

N/A

165/92

23

162/90

12

134/76

N/A

ICU DISCHARGEV

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Discharge

• BP: 134/76

• HR: 72

• Oxygen saturation: 99% (RA)

• SCr: 0.75

• BUN: 21

Signs and symptoms

Test results

Patient status

• Body temperature: 98.2 F

• Body weight: 70 kg

• Plasma potassium: 4.1

• Urine output: 40 cc/hr

ICU DISCHARGEV

The patient was monitored in the Neurosurgical ICU

for vasospasm and other complications. Because of

the hypertonic saline, the patient became

overloaded. With the help of CRRT, the patient

improved and was eventually extubated.

Patient was discharged to rehab center with focus

on neurological disorders. Follow up by PMD and

neurosurgeon demonstrated patient was near

baseline 2 weeks after discharge.

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SUMMARYV

Managing AKI in Subarachnoid Hemorrhage (SAH)

RISK

Development of AKI following

SAH can result in fluid

overload, which is associated

with increased mortality and

poorer neurologic recovery. 8-10

HEMODYNAMIC STABILITY

Hemodynamic stability and

control of intracranial pressure

are critical to neurologic

recovery after SAH and other

acute brain injuries 3,6,7,11

OPTIMIZING THERAPY

Clinical guidelines recommend CRRT over intermittent RRT for the

treatment of AKI in patients with acute brain injury, including

SAH.13-16

• Intermittent RRT can result in systemic and cerebral hemodynamic

instability and increased intracranial pressure.3,6,7,11

• As a result of the slow, steady removal of fluid and solutes, CRRT

supports stable hemodynamics and cerebral perfusion while avoiding

rapid shifts in osmotic gradients that worsen cerebral edema. 3,6,7,11

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ACRONYMS/ABBREVIATIONS/REFERENCES

ACOM, anterior communicating artery; ADQI, Acute Dialysis Quality Initiative; AKI, acute kidney injury; BFR, blood

flow rate; BP, blood pressure; BUN, blood urea nitrogen; CRRT, continuous renal replacement therapy; CXR,

chest x-ray; CT, computed tomography, Hgb, hemoglobin; HR, heart rate; ICU, intensive care unit; IHD,

intermittent hemodialysis; K+, serum potassium level, KDIGO, Kidney Disease: Improving Global Outcomes,

MAP, mean arterial pressure; MVI, multivitamin; PBP, pre-blood pump; RRT, renal replacement therapy; SAH,

subarachnoid hemorrhage; SCr, serum creatinine; SLED, sustained low-efficiency dialysis; includes sustained or

slow low-efficiency dialysis, slow extended dialysis, sustained low-efficiency daily dialysis, and sustained low-

efficiency daily diafiltration; UF, ultrafiltration

1. Connolly ES Jr, et al. Stroke. 2012 Jun;43(6):1711-37.

2. Tujjar O, et al. J Neurosurg Anesthesiol. 2017 Apr;29(2):140-149.

3. Fletcher JJ, et al. J Trauma. 2010 Jun;68(6):1506-9.

4. Rumalla K, Mittal MK. World Neurosurg. 2016

Jul;91:542-547.

5. Zacharia BE, et al. Stroke. 2009 Jul;40(7):2375-81.

6. Davenport A. Am J Kidney Dis. 2001 Mar;37(3):457-

66.

7. Davenport A. Contrib Nephrol. 2007;156:333-9.8. Claure-Del Granado R, Mehta RL. BMC Nephrol.

2016;17(1):109.

9. Zhang L, et al. J Crit Care. 2015 Aug;30(4):860.e7-13.

10. van der Jagt M. Crit Care. 2016 May 31;20(1):126.

11. Osgood M, Muehlschlegel S. Chest. 2017

Dec;152(6):1109-1111.

12. Bagshaw SM, et al. BMC Nephrol. 2004 Aug 19;5:9

13. Ostermann M, et al. Blood Purif. 2016;42(3):224-

37.

14. Bagshaw SM, et al. Intensive Care Med. 2017

Jun;43(6):841-854.15. Kidney Disease: Improving Global Outcomes

(KDIGO) Acute Kidney Injury Work Group. Kidney IntSuppl. 2012;2(1):1-138.

16. Kellum J, et al. (ADQI Workgroup). Kidney Int. 2002 Nov;62(5):1855-63.

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